Studies on Persistence

Persister cells, dormancy and infectious disease  Jan 2007 Kim Lewis

Several well-recognized puzzles in microbiology have remained unsolved for decades. These include latent bacterial infections, unculturable microorganisms, persister cells and biofilm multidrug tolerance. Accumulating evidence suggests that these seemingly disparate phenomena result from the ability of bacteria to enter into a dormant (non-dividing) state. The molecular mechanisms that underlie the formation of dormant persister cells are now being unravelled and are the focus of this Research

 Multidrug Tolerance of Biofilms and Persister Cells.  2008 K. Lewis

Bacterial populations produce a small number of dormant persister cells that exhibit multidrug tolerance. All resistance mechanisms do essentially the same thing: prevent the antibiotic from hitting a target.

Hidden in plain sight: Borrelia burgdorferi and the extracellular matrix  2007

Borrelia burgdorferi, the tick-transmitted etiologic agent of Lyme borreliosis, can colonize and persist in multiple tissue sites despite vigorous host immune responses. The extracellular matrix appears to provide a protective niche for the spirochete. Recent studies in mice suggest that B. burgdorferi interacts in various ways with collagen and its associated molecules, exploiting molecular and structural features to establish microcolonial refugia. Better knowledge of the genetic and structural bases for these interactions of B. burgdorferi with the extracellular matrix will be required before an understanding of the persistence of B. burgdorferi in the tissues and development of chronic infections can be achieved.

Persistence of Borrelia burgdorferi following Antibiotic Treatment in Mice▿ August 2007

Results indicated that following antibiotic treatment, mice remained infected with nondividing but infectious spirochetes, particularly when antibiotic treatment was commenced during the chronic stage of infection.

Emir Hodzic,  Sunlian Feng,  Kevin Holden,  Kimberly J. Freet and  Stephen W. Barthold*

Protective Niche for Borrelia burgdorferi to Evade Humoral Immunity Sept 2004

Fang Ting Liang ,  Eric L. Brown ,  Tian Wang ,  Renato V. Iozzo ,  Erol Fikrig Email the author Erol Fikrig

The Lyme disease spirochete, Borrelia burgdorferi, is an extracellular microbe that causes persistent infection despite the development of strong immune responses against the bacterium. B. burgdorferi expresses several ligand-binding lipoproteins, including the decorin-binding proteins (Dbps) A and B, which may mediate attachment to decorin, a major component of the host extracellular matrix during murine infection. We show that B. burgdorferi was better protected in the joints and skin, two tissues with a higher decorin expression, than in the urinary bladder and heart, two tissues with a lower decorin expression, during chronic infection of wild-type mice. Targeted disruption of decorin alone completely abolished the protective niche in chronically infected decorin-deficient mice but did not affect the spirochete burden during early infection. The nature of protection appeared to be specific because the spirochetes with higher outer surface protein C expression were not protected while the protective niche seemed to favor the spirochetes with a higher dbpA expression during chronic infection. These data suggest that spirochetal DbpA may interact with host decorin during infection and such interactions could be a mechanism that B. burgdorferiuses to evade humoral immunity and establish chronic infection.

Evidence assessments and guideline recommendations in Lyme disease: the clinical management of known tick bites, erythema migrans rashes and persistent disease

Thirty-four percent of a population-based, retrospective cohort were ill an average of 6.2 years after antibiotic treatment. (Lyme disease: an infectious and postinfectious syndrome.)

Sixty-two percent of a retrospective evaluation of 215 Lyme disease patients from Westchester County, NY, remained ill an average of 3.2 years after antibiotic treatment.

(The long-term clinical outcomes of Lyme disease. A population-based retrospective cohort study.

A meta-analysis of 504 patients treated for Lyme disease found this group had more fatigue, musculoskeletal pain and neurocognitive difficulties than  530 controls.  Additionally, it demonstrated that persistent Lyme disease symptoms were a distinct set of symptoms, which differed from those of fibromyalgia, chronic fatigue syndrome and depression (Post-Lyme borreliosis syndrome: a meta-analysis of reported symptoms.)


A European study of adults treated for neuroborreliosis found that at 30 months post-treatment, 16% were cognitively impaired (European neuroborreliosis: quality of life 30 months after treatment)

Daniel J. Cameron, MD MPH , Lorraine B Johnson & Elizabeth L Maloney

Isolation and polymerase chain reaction typing of Borrelia afzelii from a skin lesion in a seronegative patient with generalized ulcerating bullous lichen sclerosus et atrophicus.  February 2001

​​F. Breier, G. Khanakah, G. Stanek, G. Kunz, E. Aberer, B. Schmidt, G. Tappeiner

Despite treatment with four courses of ceftriaxone with or without methylprednisone for up to 20 days, progression of LSA was only stopped for a maximum of 1 year. Spirochaetes were isolated from skin cultures obtained from enlarging LSA lesions. These spirochaetes were identified as Borrelia afzelii by sodium dodecyl sulphate–polyacrylamide gel electrophoresis and polymerase chain reaction (PCR) analyses. However, serology for B. burgdorferi sensu lato was repeatedly negative.

Long term and repeated electron microscopy and PCR detection of Borrelia burgdorferi sensu lato after an antibiotic treatment. 2004 

Department of Infectious diseases, University Hospital, Hradec Králové, Czech Republic.


The diagnosis of Lyme disease in 18 patients has been proved by detection of Borrelia burgdorferi sensu lato when using immunoelectron microscopy or detecting its nucleic acid by PCR in the plasma or the cerebrospinal fluid. The positive results occurred in the plasma or in the cerebrospinal fluid in the period of 4-68 months after an antibiotic treatment. The typical clinical manifestations of Lyme disease were observed in 9 patients and non-specific symptoms in another 9 patients. According to presented results we can recommend repeated examination using PCR of the plasma and other biological specimens in the individuals with persistent or recurring complaints after an acute form of Lyme disease and its antibiotic treatment. Also examination of the cerebrospinal fluid with non-specific symptoms and simultaneously displayed pathology electroencephalogram and/or magnetic resonance imaging findings can be advantageous.

In Vitro Susceptibility Testing of Borrelia burgdorferi Sensu Lato Isolates Cultured from Patients with Erythema Migrans before and after Antimicrobial Chemotherapy.  2005

Klaus-Peter Hunfeld,  Eva Ruzic-Sabljic,  Douglas E. Norris,  Peter Kraiczy and  Franc Strle

Our study substantiates borrelial persistence in some EM patients at the site of the infectious lesion despite antibiotic treatment over a reasonable time period. Borrelial persistence, however, was not caused by increasing MICs or minimal borreliacidal concentrations in these isolates. Therefore, resistance mechanisms other than acquired resistance to antimicrobial agents should be considered in patients with LB resistant to treatment.

Bowelia Burgorferi Detected by Culture and PCR in Clinical Relapse of Disseminated Lyme Borreliosis    Jul 2009

We conclude that the treatment of Lyme borreliosis with appropriate antibiotics for even more than 3 months may not always eradicate the spirochete. By using PCR, it is possible to avoid unnecessary retreatment of patients with ‘post-Lyme syndrome’ and those with ‘serological scars’ remaining detectable for months or years after infection.

Detection of Borrelia burgdorferi by polymerase chain reaction in synovial membrane, but not in synovial fluid from patients with persisting Lyme arthritis after antibiotic therapy  1998

Susanne Priema,  Gerd R Burmestera,  Thomas Kamradta,b,  Karsten Wolbarta,  Michael G Rittigc,  Andreas Krausea


These data suggest that in patients with treatment resistant Lyme arthritis negative PCR results in SF after antibiotic therapy do not rule out the intraarticular persistence of B burgdorferi DNA. Therefore, in these patients both SF and SM should be analysed for borrelial DNA by PCR as positive results in SM are strongly suggestive of ongoing infection.

Persistence of Borrelia burgdorferi in rhesus macaques following antibiotic treatment of disseminated infection.  Epub 2012 Jan 11

Embers ME1, Barthold SW, Borda JT, Bowers L, Doyle L, Hodzic E, Jacobs MB, Hasenkampf NR, Martin DS, Narasimhan S, Phillippi-Falkenstein KM, Purcell JE, Ratterree MS, Philipp MT.

The persistence of symptoms in Lyme disease patients following antibiotic therapy, and their causes, continue to be a matter of intense controversy. The studies presented here explore antibiotic efficacy using nonhuman primates. Rhesus macaques were infected with B. burgdorferi and a portion received aggressive antibiotic therapy 4-6 months later. Multiple methods were utilized for detection of residual organisms, including the feeding of lab-reared ticks on monkeys (xenodiagnosis), culture, immunofluorescence and PCR. Antibody responses to the B. burgdorferi-specific C6 diagnostic peptide were measured longitudinally and declined in all treated animals. B. burgdorferi antigen, DNA and RNA were detected in the tissues of treated animals. Finally, small numbers of intact spirochetes were recovered by xenodiagnosis from treated monkeys. These results demonstrate that B. burgdorferi can withstand antibiotic treatment, administered post-dissemination, in a primate host. Though B. burgdorferi is not known to possess resistance mechanisms and is susceptible to the standard antibiotics (doxycycline, ceftriaxone) in vitro, it appears to become tolerant post-dissemination in the primate host. This finding raises important questions about the pathogenicity of antibiotic-tolerant persisters and whether or not they can contribute to symptoms post-treatment.